Provider Demographics
NPI:1851572044
Name:PRENTICE, MARY KATHERINE (MFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0047
Mailing Address - Country:US
Mailing Address - Phone:760-934-0355
Mailing Address - Fax:760-934-0355
Practice Address - Street 1:549 OLD MAMMOTH RD.
Practice Address - Street 2:SUITE #10
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546
Practice Address - Country:US
Practice Address - Phone:760-934-0355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33459106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist